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Executive Summary of Responses to RFI - The Nursing Home Transition and Diversion Waiver

August 24, 2005

The NYS Department of Health (DOH) issued a Request for Information (RFI) on May 6, 2005 seeking public input for development of a federal waiver to implement a Nursing Home Transition and Diversion (NHTD) program. This waiver will provide community-based services for persons eighteen and older who would otherwise be cared for in a nursing facility and who, considered as an aggregate group, can be served at less cost in a community setting.

Eighty responses were received from independent living centers (ILCs) and advocates; providers; professional associations; local government agencies representing twenty-two Counties and the City of New York; and other State government agencies. The following provides an executive summary of those responses arranged by category of questions posed in the RFI.

Although the NHTD statute specifies eligible participants as those persons 18 and older who would otherwise be cared for in a nursing facility, some representatives of each respondent group suggested targeting a narrower population. Such alternative participant groups included: all those under age 65 who are currently residing in nursing homes or who are at risk of permanent transition from the community to a nursing home, and only those over age 18 but under 65 residing in nursing homes. In addition, some respondents had concerns about the need to differentiate between participants appropriate for this waiver and the Long Term Home Health Care Program (LTHHCP) or Managed Long Term Care (MLTC) programs.

There was consensus that the NHTD waiver must be widely publicized through traditional sources , including service providers, Local Department of Social Services (LDSS), ILC's and other non-traditional sources such as medical offices; public media; housing, employment, community agencies. Suggestions and mechanisms were offered to insure that hospital and nursing home discharge planners talk with patients or residents about the waiver to ascertain and document their interest in participating in the program.

Respondents across all categories suggested additional eligibility criteria for admission to the waiver. For example, some providers and provider associations included being self-directing and demonstrably able to be safely served in the community. Such participation standards should be strictly and uniformly enforced throughout the state to avoid variances in implementation between counties. Others recommend requiring a documented need for waiver services by a medical professional. Local government agencies agreed on the importance of a sign-off from a medical professional, stressing that participants' community supports must be adequate and clearly documented, that service plans be cost effective, and that the responsible LDSS agree that the individual is financially eligible for the waiver prior to enrollment.

ILCs and advocate groups voiced the individual's perspective, emphasizing the importance of understanding the basic premise of a right to the dignity of risk in planning for community-based care. There was broad agreement that individuals with substance abuse problems must be involved in the planning and be compliant with their treatment programs. Several respondents proposed that the NHTD waiver allow presumptive Medicaid eligibility to avoid delays in hospital discharges.

Respondents generally recommended that a flexible, holistic, comprehensive assessment tool be developed to establish the medical, social, psychological, educational and vocational status/needs of a potential participant, and that it be required as a replacement for the various existing assessment methods currently in use across the State. However, pending availability of a uniform assessment tool, many currently available tools were suggested that could be used in the interim, including: the NYS Patient Review Instrument and SCREEN, Medical Assessment Abstract DMS-1 and Katz Index of Independence in Activities of Daily Living, Federal Minimum Data Set and Outcome and Assessment Information Set, Adaptive Behavior Assessment Scales, New York City Home Care Assessment Form M11, New Edmonton Functional Assessment Tool and Barthel Index.

Coordination with Other Medicaid Functions: Eligibility Determination and Participation in Other Waiver Programs

Local governments stressed the importance of cooperation and collaboration between RRDCs and local government agencies to assure the success of NHTD waiver program. Agreement on participant eligibility, prior authorization of services, and definition of each entity's roles and responsibilities were noted as particularly important. In this regard, most local government respondents indicated that county government agencies should have the major role in participant need assessment and service plan authorization to assure that the waiver services are used only for those who otherwise could not live in the community. Several respondents pointed out that there are already local point of entry processes in place that successfully coordinate these functions.

Providers raised concerns that the NHTD waiver will diminish participation in other programs such as the LTHHCP and MMLTC making them less cost effective and efficient. ILCs and advocates stressed the importance of consumer choice and the need for cooperation among all parties so as not to delay delivery of necessary waiver services. In contrast to the local government position, they uniformly opposed county involvement except to authorize financial eligibility for Medicaid.

Community Capacity and Services - To Be Offered and Expected Availability Gaps

Respondents generally agreed that all services available under current waivers should be offered as well as the enhanced NHTD services in order to avoid gaps in service that would prohibit participants' ability to remain or transition back into the community. For instance, mental health, substance abuse, vocational and educational opportunities, training in negotiating community service systems and opportunities for social day services were frequently mentioned as essential to successful community integration.

Virtually all respondents cited three major problems that will affect community capacity to fully realize the intended goal for the waiver: housing, transportation and work force shortages.

Service Plans

There was a clear division among respondent groups concerning separation of waiver service coordination from the provision of other waiver services. Local governments representatives stated that service coordination should be separate from providing services. Providers and provider associations clearly stated that coordination was an integral part of service provision and that the functions should not be separated. ILCs and advocates suggested that consumers should always have a choice of providers and be able to receive their service coordination and services from the same or separate organizations.

It was recommended that feedback about the quality and satisfaction with the waiver program be obtained from consumers through peer reviews, telephone calls, and in-home surveys performed on a regular basis by an unbiased entity. Responders suggested that participant surveys focus on service outcomes as measured by defined benchmarks. Guidelines were offered to help establish a successful person-centered quality assurance process.

Electronic Data and Management Reports

All respondents agreed that electronic data sharing and storage was essential. However, there was concern about the cost of hardware, software and user staff training to develop and implement a statewide system. Suggestions included the development of a standard format for data entry with ease of file transfer and sufficient storage capability; electronic collation of applications and service coordination; process/software enhancements without complete system redesign or interruption of services; non-duplicative billing methods and acceptance of authorization through electronic signatures.